1 CHESTNUT ST - BUILDING INSPECTION -PLwftl6itMltaT-BE fiLmEO-AW A11PROVE0 BY TW -
JNSPrFCIAfI PAlOA TD.A_PEANUT MO GRANTED
/ CITY 0-F SALEM
No. ? D �O s\ Date 1
1 r
Is Property Located in Location of /
the Histortc District? Yes Building
Is Property Located In
the Conservatlon Ares? Yes NO
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) R Ror
pair Install Siding, Construct Deck, Shed, Pool,
Reeplace, Other:
PLEASE RLL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name �iY// i �c it
Address & Phone / t�,f r�
Architect's Name
Address & Phone
Mechanics Name
Address & Phone
What Is the purpose&MMkV?
Materiel of b Awv? M a dwam,for how many families?
WN bukkV cordorm to law? Asbestos?
Estlrnated cost v� CJD- City License tf N p' state Ucerrse• 7
5 Bares Igrrovesant
Lie. /
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE p
MAIL PERMIT T0:
APPLICATION FOR
PERWT TO
p
ee
LOCATIONG.
PERMIT GRANTED
AP RO4D
INSPECTOA OF BUILDINGS
s _
The Commonwealth of Massachusetts
Department of Industrial Accidents
Olflea ollal' agatloas
600 Washington Street, 7t6 Floor
Boston, Mass. 02111
t'4 Workers' Compensation Insurance Affidavit: Buildin /Plum bin lectrical Contractors
name , Ac/rn l L�
city state �/� zim phone#
work site location(full address)
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction ❑Remodel
❑ I am_a sole proprietor and have no one working in any capacity. ❑ Building Addition
go --
am an employer providing-workers' compensation for my employees,working on thisjob.
address:
one iW
❑ 1 am a sole proprietor,general contractor,or homeow (circle one)and have hired the contractors listed below who have
the following workers' compensation polices: IV
comnanv name:
address:
city:
g
t �,�rfft oollcv!►, M k.�. ,
Company name: - -
address;
on-policy L��
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposkbo of criminal penalties ors fine up to 51,500.011 ad/or
one years'imprisonment in well as civil penalties in the form of a STOP WORK ORDER and a ane of S100.00 a day against me. i understand that a
copy of this statement may be forwarded to the Office of Investigations orthe DIA for coverage verification.
Ida hereby certify under e p 'ns an en ties of perjury that the information provided above is true and c rrect.
Signature2"'L--�_ Date J' Ci
Print name ,� 2ce+ Phone# - �Y
Lcheckir
nly do not write in this area to be completed by city or town omcial
: permitlicensep ❑Building Department
❑Licensing Board
mmediate response u required ❑Selectmen's Office
❑Health Department
on: phone q ❑Othernl
CITY OF SALEMo MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
j. SALEM, MAOI 970
TEL. (978)745-9595 ExT. 380
FAx (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
of Building Permit# - ; all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S 150A. / Q
The debris will be disposed of at: /l/ �S �� < ' 5 6"? /-5
Location of Fac' ' Y-4 e—;,'
Signature of P t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
�
I<` e`r'r✓ /(oma , /l .-< , � C�
Firm Name, if any/
Address, City & State
The above statute requires that debris from the demolition,renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
iridicate the location of the facility.